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7. Hand and Wrist MCQs

Practice Set 226 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 4501

Topic: 7. Hand and Wrist

A 45-year-old male undergoes surgical repair of a chronic distal biceps rupture using a two-incision technique. Postoperatively, he demonstrates weakness in wrist extension and finger extension, but normal triceps strength. Which nerve was most likely injured during the procedure?

. Anterior interosseous nerve
. Median nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Ulnar nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is at risk during distal biceps repair, especially in a two-incision technique if the forearm is not kept fully pronated during the posterolateral exposure. The PIN innervates the extensor muscles of the wrist and digits.

Question 4502

Topic: Nerve & Tendon

A 52-year-old female undergoes an anterior subcutaneous transposition of the ulnar nerve for severe cubital tunnel syndrome. During the proximal dissection, a fascial band located roughly 8 cm proximal to the medial epicondyle must be meticulously released to prevent kinking of the transposed nerve. What is this structure called?

. Ligament of Struthers
. Arcade of Frohse
. Arcade of Struthers
. Lacertus fibrosus
. Osborne's ligament

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The Arcade of Struthers is a fascial band bridging the medial intermuscular septum to the medial head of the triceps, located about 8 cm proximal to the medial epicondyle. It is a critical potential site of ulnar nerve compression that must be released during an anterior transposition.

Question 4503

Topic: 7. Hand and Wrist

A 40-year-old weightlifter undergoes a single-incision distal biceps tendon repair. Postoperatively, he is unable to extend his thumb and fingers at the MCP joints, but wrist extension is preserved with radial deviation. Which nerve was most likely injured during the procedure?

. Posterior interosseous nerve
. Anterior interosseous nerve
. Radial nerve (main trunk)
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

Single-incision distal biceps repairs risk injury to the posterior interosseous nerve (PIN). PIN palsy presents with loss of finger and thumb extension but preserved wrist extension, often with radial deviation due to an intact ECRL supplied by the radial nerve proper.

Question 4504

Topic: Wrist & Carpus

A 42-year-old falls from a ladder, sustaining a comminuted, unsalvageable radial head fracture. Wrist pain is also noted, and distal radioulnar joint (DRUJ) instability is confirmed. Which of the following is strictly contraindicated in this patient's management?

. Radial head excision alone
. Radial head arthroplasty
. TFCC repair
. Ulnar shortening osteotomy
. Pinning of the DRUJ in supination

Correct Answer & Explanation

. Radial head excision alone

Explanation

This patient has an Essex-Lopresti injury, characterized by a radial head fracture, interosseous membrane tear, and DRUJ disruption. Radial head excision alone is strictly contraindicated as it removes the primary restraint to proximal radial migration, leading to severe ulnocarpal impaction.

Question 4505

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with progressive dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, consistent with Lichtman Stage IIIA Kienböck's disease, and ulnar negative variance. Which of the following surgical interventions is most appropriate?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Capitate shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Lichtman Stage IIIA Kienböck's disease (lunate collapse but no fixed scaphoid rotation or carpal arthritis) with ulnar negative variance, joint-leveling procedures such as a radial shortening osteotomy are indicated. This shifts mechanical load off the lunate and onto the ulnocarpal joint.

Question 4506

Topic: Wrist & Carpus

Which of the following radiographic parameters is the most critical to restore to prevent long-term radiocarpal arthrosis following surgical fixation of an intra-articular distal radius fracture?

. Volar tilt
. Radial inclination
. Radial height
. Articular step-off
. Ulnar variance

Correct Answer & Explanation

. Volar tilt

Explanation

While restoring extra-articular alignment parameters is important for kinematics, restoring articular congruity (minimizing step-off to less than 1-2 mm) is the single most critical factor in preventing the development of post-traumatic radiocarpal arthrosis after an intra-articular fracture.

Question 4507

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration over the palmar aspect of his proximal phalanx. Examination reveals an inability to flex the PIP and DIP joints of the index finger. In which flexor tendon zone did this injury occur?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

The laceration is over the proximal phalanx, which corresponds to Zone II (historically termed 'No Man's Land'). This zone contains both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons within the tight fibro-osseous sheath.

Question 4508

Topic: Nerve & Tendon

A patient with severe carpal tunnel syndrome exhibits profound thenar atrophy. Which of the following muscles is primarily innervated by the recurrent motor branch of the median nerve and is expected to be most atrophied?

. Adductor pollicis
. Opponens pollicis
. Deep head of the flexor pollicis brevis
. First dorsal interosseous
. Palmaris brevis

Correct Answer & Explanation

. Adductor pollicis

Explanation

The recurrent motor branch of the median nerve innervates the Opponens pollicis, Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis. The adductor pollicis and the deep head of the flexor pollicis brevis are typically innervated by the ulnar nerve.

Question 4509

Topic: 7. Hand and Wrist

A 68-year-old man presents with progressive clumsiness in his hands and difficulty with fine motor tasks. Physical examination reveals a positive Hoffmann sign bilaterally. This reflex is elicited by:

. Tapping the volar aspect of the wrist
. Flicking the volar surface of the distal phalanx of the middle finger
. Stroking the lateral aspect of the plantar surface of the foot
. Quickly dorsiflexing the ankle
. Striking the brachioradialis tendon

Correct Answer & Explanation

. Tapping the volar aspect of the wrist

Explanation

A positive Hoffmann sign indicates an upper motor neuron lesion (such as cervical spondylotic myelopathy) and is elicited by flicking the volar surface of the distal phalanx of the middle finger. A positive response is a reflex flexion of the thumb and/or index finger.

Question 4510

Topic: 7. Hand and Wrist

A 45-year-old cyclist complains of numbness in his ring and small fingers after long rides. Examination reveals weakness in finger abduction and adduction but normal wrist flexion. Tinel's sign is positive at the wrist but negative at the elbow. Where is the most likely site of compression?

. Cubital tunnel
. Carpal tunnel
. Guyon's canal
. Struthers arcade
. Ligament of Struthers

Correct Answer & Explanation

. Cubital tunnel

Explanation

Cyclist's palsy often involves compression of the ulnar nerve at Guyon's canal (ulnar tunnel) in the wrist. Symptoms include intrinsic muscle weakness and sensory deficits in the ulnar digits. Flexor carpi ulnaris (FCU) function is spared because its innervation branches off proximal to the wrist.

Question 4511

Topic: Wrist & Carpus

A 22-year-old man falls onto an outstretched hand and has pain in the anatomic snuffbox. Initial radiographs are negative for a fracture. What is the most appropriate initial management?

. Reassurance and regular activity
. Elastic bandage and NSAIDs
. Thumb spica splint and repeat radiographs in 10-14 days
. Immediate open reduction and internal fixation
. Immediate MRI to rule out perilunate dislocation

Correct Answer & Explanation

. Reassurance and regular activity

Explanation

A patient with anatomic snuffbox tenderness but negative initial radiographs should be clinically presumed to have an occult scaphoid fracture. The standard of care is immobilization in a thumb spica splint or cast and re-evaluation with repeat radiographs in 10-14 days, or alternatively obtaining an acute MRI.

Question 4512

Topic: 7. Hand and Wrist
A 35-year-old male laborer presents with chronic, progressive wrist pain and stiffness. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is spared. What is the most appropriate surgical treatment?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Scaphoid nonunion takedown and bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III (involvement of the capitolunate joint). Proximal row carpectomy (PRC) is contraindicated in the presence of capitate arthritis, because the capitate acts as the new articular surface in the lunate fossa. Scaphoid excision and four-corner fusion is the treatment of choice when the radiolunate joint is preserved but the capitolunate joint is arthritic.

Question 4513

Topic: 7. Hand and Wrist

During the repair of a complete flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) laceration in Zone II of the hand, preserving or reconstructing specific pulleys is vital to prevent bowstringing. Which pulley is biomechanically the most critical to preserve over the proximal phalanx?

. A1 pulley
. A2 pulley
. A3 pulley
. C1 pulley
. C2 pulley

Correct Answer & Explanation

. A1 pulley

Explanation

The A2 and A4 pulleys are the most critical biomechanically to prevent bowstringing of the flexor tendons and ensure appropriate tendon excursion. The A2 pulley is located over the proximal half of the proximal phalanx, while the A4 pulley is located over the middle phalanx.

Question 4514

Topic: 7. Hand and Wrist

A 40-year-old carpenter suffers a laceration over the volar aspect of his proximal phalanx in zone II. Both the FDS and FDP tendons are severed. To optimize tendon gliding and minimize rupture risk, what is the ideal number of core suture strands crossing the repair site?

. 2 strands
. 4 to 6 strands
. 8 to 10 strands
. 12 strands
. Only epitendinous repair is required

Correct Answer & Explanation

. 2 strands

Explanation

A 4-strand or 6-strand core suture repair significantly increases the tensile strength of the tendon while minimizing bulk. This strength is necessary to allow for early active motion protocols, which prevent adhesions in zone II.

Question 4515

Topic: 7. Hand and Wrist
A 30-year-old carpenter lacerates his index finger volar surface at the level of the proximal phalanx, disrupting both the FDS and FDP tendons. This injury corresponds to which flexor tendon zone, and what is its primary anatomical characteristic?
. Zone I; distal to the FDS insertion
. Zone II; containing the fibro-osseous sheath and Camper's chiasm
. Zone III; origin of the lumbrical muscles
. Zone IV; within the carpal tunnel
. Zone V; proximal to the carpal tunnel

Correct Answer & Explanation

. Zone II; containing the fibro-osseous sheath and Camper's chiasm

Explanation

Lacerations at the level of the proximal phalanx involve Zone II, historically known as "no man's land". This zone contains both the FDS and FDP within the tight fibro-osseous digital sheath, making surgical repair prone to adhesions.

Question 4516

Topic: 7. Hand and Wrist

A 62-year-old female sustains a dorsally displaced distal radius fracture. During conservative management in a cast, she reports escalating numbness in her thumb, index, and long fingers. Which nerve is most commonly compressed in this setting?

. Radial nerve
. Ulnar nerve
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

Acute carpal tunnel syndrome, caused by compression of the median nerve, is the most common neurologic complication associated with distal radius fractures. Treatment involves removing constrictive casts and potentially surgical release if symptoms persist.

Question 4517

Topic: Wrist & Carpus

A 60-year-old female sustains a volar Barton's fracture of the distal radius. Which of the following ligaments remains attached to the displaced volar marginal articular fragment, causing the carpus to translate volarly with the fracture?

. Dorsal radiocarpal ligament
. Radioscaphocapitate ligament
. Triangular fibrocartilage complex
. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament

Correct Answer & Explanation

. Dorsal radiocarpal ligament

Explanation

A volar Barton's fracture is a shear fracture of the volar articular margin of the distal radius. The stout volar radiocarpal ligaments—specifically the radioscaphocapitate, long radiolunate, and short radiolunate ligaments—remain attached to this volar fragment. Intact ligaments cause the carpus to subluxate or dislocate volarly in concert with the bony fragment.

Question 4518

Topic: 7. Hand and Wrist

A 22-year-old male presents with a displaced fracture through the proximal pole of the scaphoid. The high risk of avascular necrosis in this region is primarily due to retrograde blood flow originating from which of the following vessels?

. Superficial palmar arch
. Deep palmar arch
. Ulnar artery branches
. Dorsal carpal branch of the radial artery
. Volar carpal branch of the radial artery

Correct Answer & Explanation

. Superficial palmar arch

Explanation

The blood supply to the scaphoid is predominantly provided by the dorsal carpal branch of the radial artery, which enters the bone distally and flows in a retrograde fashion toward the proximal pole. Fractures through the waist or proximal pole disrupt this delicate retrograde flow, rendering the proximal pole highly susceptible to avascular necrosis.

Question 4519

Topic: 7. Hand and Wrist

A 65-year-old female presents with a volar Barton's fracture of the distal radius. Due to strong ligamentous attachments, which carpal bone predictably subluxates proximally and volarly with the intra-articular distal radius fragment?

. Scaphoid
. Lunate
. Triquetrum
. Pisiform
. Capitate

Correct Answer & Explanation

. Scaphoid

Explanation

A volar Barton's fracture is a shear fracture of the volar margin of the distal radius. The lunate typically subluxates or dislocates with the volar articular fragment due to the stout, unyielding attachment of the short radiolunate ligament.

Question 4520

Topic: 7. Hand and Wrist

A 30-year-old woman undergoes volar locked plating for a distal radius fracture. Six months later, she presents with a new-onset inability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause?

. Extensor indicis proprius to extensor pollicis longus rupture
. Flexor pollicis longus tendon rupture due to prominent hardware at the watershed line
. Median nerve entrapment at the carpal tunnel
. Anterior interosseous nerve neuropraxia
. Ischemic adhesions of the flexor digitorum profundus tendons

Correct Answer & Explanation

. Extensor indicis proprius to extensor pollicis longus rupture

Explanation

Placing a volar plate distally over the watershed line of the distal radius places the flexor pollicis longus (FPL) tendon at high risk for attrition and spontaneous rupture.

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